Minimally invasive approach to a deep-seated motor eloquent brain tumour: a technical note.

Deep-seated brain tumours represent a unique neurosurgical challenge as they are often surrounded by eloquent structures. We describe a minimally invasive technique using tubular retractors and intraoperative neurophysiology monitoring for open biopsy of a deep-seated lesion surrounded by the corticospinal tract. We used preoperative functional mapping with diffusion tensor imaging tractography and navigated transcranial magnetic stimulation to identify a safe surgical corridor. We also used 5-Aminolevulinic Acid induced fluorescence to identify the lesion intraoperatively and optimize tissue samples obtained for histopathological diagnosis. We found the use of these tools improved the safety of surgery and reduced the risk of surgical morbidity.

Intraoperative Sneezing Secondary to Indirect Olfactory Nerve Stimulation.

Sneezing is a poorly understood, protective reflex response. It's characterized by the following sequence: eye closure, inspiration, glottic closure, forced expiration with sudden glottic opening, and release of an elevated intrathoracic pressure creating a flow of explosive air through the nose.1 Studies have indicated an anatomic sneezing area of the brainstem corresponding to the central recipient zone of the nasal sensory neurons in the lateral medulla.2 The traditional pathophysiology of the sneeze is thought to begin by stimulation of the distal branches of the trigeminal nerve within the nasal mucosa. Afferent neural stimuli are transmitted to the trigeminal ganglion and then the lateral medulla. The efferent phase then begins, giving rise to the sneezing sequence described earlier.1 In addition to direct nasal irritation, sneezing has been shown to be triggered by several other causes (Table 1). This suggests that alternative mechanisms of sneeze induction other than direct nasal stimulation exist. We report a case of a 34-year-old man undergoing an awake craniotomy for a recurrent World Health Organization grade 2 oligodendroglioma (IDH-mutant, 1p19q-codeleted, ATRX preserved). During the operation we elicited a sneeze response on 3 occasions on stimulation of the olfactory nerve (Video 1). Although we cannot completely exclude costimulation of the sensory trigeminal terminations in the anterior fossa floor, the actual sneezing occurred during tumor peeling away from the arachnoid surface overlaying the olfactory nerve. This suggests a potential accessory route of sneeze stimulation involving the olfactory nerve distinct from the previously described trigemino-related, autonomic (sympathetic and parasympathetic systems) and psychogenic etiologies.

Intraoperative ultrasound to aid resection of a peritorcular meningioma: a technical note.

Surgery for meningiomas involving dural venous sinuses is challenging. We describe a case of a peritorcular meningioma involving major venous sinuses, which was removed using a venous sparing approach with the aid of intraoperative ultrasound. We found ultrasound to be a useful adjunct as it enabled us to get real-time information about the location of venous structures, their function and demonstrate dynamic changes in blood flow during surgery.

Which factors influence the decision to transfer patients with traumatic brain injury to a neurosurgery unit in a major trauma network?

Objectives: Within the pan London Major Trauma System many patients with minor or non-life threatening traumatic brain injury (TBI) remain at their local hospital and are not transferred to a major trauma centre (MTC). Our aim was to identify factors that influence the decision to transfer patients with TBI to a neurosurgical centre.Methods: This is a single centre prospective cohort study of all patients with TBI referred to our neurosurgery unit from regional acute hospitals over a 4-month period (Sept 2016-Jan 2017). Our primary outcome was transferred to a neurosurgical centre. We identified the following factors that may predict decision to transfer: patient demographics, transfer distance, antithrombotic therapy and severity of TBI based on initial Glasgow Coma Scale (GCS) and Marshall CT score. A multivariable logistic regression analysis was performed.Results: A total of 339 patients were referred from regional hospitals with TBI and of these, 53 (15.6%) were transferred to our hospital. The mean age of patients referred was 70.6 years, 62.5% were men and 43% on antithrombotic drugs. Eighty-six percent of patients had mild TBI (GCS 13-15) on initial assessment and 79% had a Marshall CT score of 2. The adjusted analysis revealed only higher age, higher Marshall Score, the presence of chronic subdural haematoma (CSDH), the presence of contusion(s) and fracture(s) predicted transfer (p<.05). Subgroup analysis consistently showed a higher Marshall score predicted transfer (p<.05).Conclusions: In our cohort higher Marshall score consistently predicted transfer to our neurosurgical centre. Presenting GCS, transfer distance and antithrombotic therapy did not influence decision to transfer.

Pancoast tumour presenting as shoulder pain with Horner's syndrome.

A 54-year-old man presented to the emergency department with a 4-week history of right shoulder pain radiating down his arm, with some associated sensory loss. Further questioning and examination in the department revealed a classical Horner's syndrome; miosis, partial ptosis and hemifacial anhidrosis. An initial chest X-ray was deemed to be unremarkable; however, further review by a radiologist noted asymmetrical right apical thickening. A subsequent high-resolution CT scan of the chest revealed a right-sided Pancoast tumour. This case highlights the importance of a thorough history and examination in identifying a rare cause of shoulder and/or back pain.

Undergraduate neurosurgical conferences - what role do they play?

INTRODUCTION: Undergraduate student conferences provide networking opportunities for students interested in exploring a speciality. The ability to meet with like-minded students, engage with senior clinicians and experience the practical side of a speciality are valuable in shaping the career trajectory of undergraduates. We report our experience of developing a national undergraduate neurosurgery conference - a combined project between the medical students of King's College London School of Medicine and the neurosurgery department at King's College Hospital NHS Foundation Trust. DESIGN: Evaluation of conference design and student feedback. METHODS: The conference was organised by medical students with support from a neurosurgical unit. Senior clinicians and trainees helped design practical workshops and a focused programme. Questionnaires were distributed before and after the conference to assess the quality of content and impact of the conference on students. RESULTS: Prior to the conference, 80.7% of respondents stated they were interested in a career in neurosurgery. After the conference the figure rose to 88.9%. The percentage of students who felt they understood what a career in neurosurgery involves increased from 38.6% to 92.1% of respondents. 39.0% of participants had no neurosurgery exposure prior to the conference. 91.9% of participants agreed or strongly agreed they would be more confident engaging with a neurosurgical department following the conference. All participants agreed (29.0%) or strongly agreed (71.0%) that they would recommend this conference to a colleague. CONCLUSIONS: Student conferences are a valuable method of increasing exposure to a career in neurosurgery. They serve a great purpose in demystifying the specialty and guiding those with an interest through the steps required to enter and progress.

Spinal subdural hematoma post foramen magnum decompression-rare complication in a patient with rhomboencephalosynapsis.

Spinal subdural hematoma (SSDH) as a complication of posterior fossa surgery is extremely rare and can have potentially serious consequences. We report a case of delayed extensive SSHD presenting as cauda equina syndrome (CES) following foramen magnum decompression and occipito-cervical (OC) fusion.

Towards evidence based emergency medicine: Best BETs from the Manchester Royal Infirmary. BET 1: Targeted blood pressure management in the hyperacute and acute stages following spontaneous intracerebral haemorrhage.

A short cut review was carried out to establish whether targeted blood pressure management in the hyperacute and acute stages following spontaneous intracerebral haemorrhage. 275 papers were found of which 6 presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. The clinical bottom line is the current evidence suggests in patients with hypertension following spontaneous intracerebral haemorrhage, intensive lowering of SBP to a target of less than 140mmHg in the hyperacute and acute stages is safe and may improve functional recovery.